Dog bite injuries and armed conflict-related environmental stressors: a nationwide population-based time-series study

Dog bite injuries and armed conflict-related environmental stressors: a nationwide population-based time-series study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Dog bite injuries and armed conflict-related environmental stressors: a nationwide population-based time-series study Shon Shabat, Lia Schoenfeld, Adi Turjeman, Sigal Fleishman, Dean Ad-El, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8950975/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Apr, 2026 Read the published version in Injury Epidemiology → Version 1 posted 11 You are reading this latest preprint version Abstract Background : Dog bite injuries pose a substantial public health burden worldwide. Environmental and acoustic stressors may contribute to canine behavioral dysregulation. However, there are as yet no population-level studies evaluating whether the incidence of dog bites increases during periods of armed conflict. The present study was conducted in Israel where the population is routinely exposed to an episodic pattern of high-intensity conflicts (escalation) alternating with periods of calm (de-escalation), providing a unique natural experiment to examine the effect of environmental stressors on population-level modifiers of injury risk. Methods : This nationwide retrospective observational study covered the decade from 2014 to 2025. Healthcare-encounter data were used to capture dog bite-related diagnoses in both hospital and community settings. Exposure to armed conflict-related environmental stress was operationalized using the number of civil defense sirens per month, categorized as none (0), low (<500), or high (≥500) and aggregated by geographic region (North, Center, South). Monthly dog bite counts were modeled using negative binomial regression adjusted for region, seasonality, age group, sex, and socioeconomic status. Secondary outcomes were hospitalization within 7 days and surgical intervention within 30 days, reflecting injury severity. Results : A total of 63,285 dog bite-related encounters were identified. Compared to months with no sirens, adjusted dog bite incidence increased by 15% during low-exposure months (IRR 1.15, 95% CI 1.13-1.18) and by 33% during high-exposure months (IRR 1.33, 95% CI 1.28-1.37), demonstrating a graded exposure-response association. High exposure was associated with increased odds of surgical intervention within 30 days (OR 1.09, 95% CI 1.02-1.16; P =0.013). Conclusions : This study provides the first population-level evidence linking armed conflict-related environmental stressors to increased dog bite incidence, using a quantitative graded exposure measure rather than a binary conflict-period definition. Dog bite prevention and healthcare preparedness should be taken into consideration in civilian injury mitigation strategies during armed conflict. Dog bite Armed conflict Environmental stressors Injury prevention Population-based study Figures Figure 1 Figure 2 Background Dog bites are a significant and growing public health concern worldwide, with millions of cases reported annually. In the United States, dog bites rank among the leading causes of nonfatal emergency department visits, with approximately 344,000 encounters per year and an incidence of up to 225 per 100,000 population [ 1 ]. Dog bite injuries pose a substantial physical, psychological, and economic burden, particularly among pediatric populations [ 2 ]. The etiology is multifactorial, involving dog-specific characteristics such as breed, sex, training, and behavioral traits, in addition to human behavior and environmental stressors that may alter canine responses. The stress exposure may be either acute or chronic [ 3 , 4 ]. Among the potential environmental stressors, several studies have identified loud noises as major contributing factors to anxiety-related and behavior dysregulation and aggression in dogs [ 5 , 6 , 7 ]. The most common noises that elicit fear responses are high-decibel fireworks, thunderstorms, sirens, and explosions [ 7 , 8 ]. Experimental studies examining controlled acoustic environments reported physiological stress responses in dogs, including elevated cortisol levels and increased heart rate, supporting the biological plausibility of noise-induced behavioral changes [ 8 , 9 , 10 ]. Besides such external stimuli, dogs are sensitive to their living conditions and the emotional states and behavioral patterns of their owners. Heightened stress, fear, and anxiety among caregivers may contribute to altered animal handling, reduced tolerance, and more unpredictable interactions, potentially lowering the threshold for aggressive canine responses. During the COVID-19 pandemic, multiple studies reported an increase in dog bite injuries, particularly among children, which were attributed to disrupted routines, increased household stress, reduced supervision, and prolonged close contact between people and pets [ 11 , 12 ]. These observations underscore how sustained environmental and psychosocial stressors can influence human-animal interactions and increase the risk of dog bite injuries. Beyond identifying individual-level determinants, dog-bite injuries can be studied using an ecological injury-risk model, examining changes in exposure patterns and susceptibility as a function of multiple, interacting factors across different levels of organization within whole environmental systems. In this context, armed conflict represents a unique population-level stressor capable of modifying the risk of dog bite injury through different, concurrent, pathways. It may simultaneously alter physical environmental conditions (e.g., high-intensity auditory stimuli including civil defense sirens, explosions, gunfire, and noise generated by aircraft, drones, and incoming or outgoing projectiles), human behavior and routines (e.g., time spent at home and supervision patterns), and psychosocial vulnerability (e.g., heightened anxiety and emotional tension). The stressors may occur as discrete acute events or as repeated and prolonged episodes over weeks or months. Accordingly, research conducted in disaster areas revealed significant behavioral changes in companion animals including increased anxiety, heightened reactivity, and unpredictable conduct [ 13 – 15 ]. Taken together, these findings suggest that armed conflict-related environmental stressors may increase both human and canine stress, thereby modifying human-animal interaction dynamics and increasing the likelihood of bite events, potentially with greater injury severity. Despite the growing recognition of the behavioral effects of environmental stressors on companion animals, empirical data on the relationship between armed conflict-related environmental stress and dog bite incidence remain limited. To our knowledge, there are no published systematic, population-level studies of armed conflict stressors as modifiers of injury risk. Israel's recurrent exposure to fluctuating intensities of armed conflict over the past decade, characterized by intermittent periods of escalation interspersed with intervals of relative calm, provides a unique natural experiment to examine this issue. Moreover, the nationwide availability of civil defense siren records makes it possible to use air raid alerts as a precise, objective proxy to quantify acute and cumulative environmental stress exposure, overall and across time and geography. The primary aim of the present study was to evaluate the association between armed conflict-related environmental stress and the incidence of dog bite injuries requiring medical evaluation using civil defense siren activity as an objective proxy for periods of escalation. The secondary aim were to determine whether the level of stressor is related to the severity of injury, as reflected by the need for hospital admission or operative management. Methods A retrospective, nationwide, observational study was conducted, spanning the decade from 2014 to 2025, during which the Israeli population was exposed to a cycle of high-intensity military conflicts and heightened civil defense siren activity (escalation) interspersed with intervals of calm (de-escalation). Healthcare encounter data were extracted at the end of the study from the research data-sharing platform (powered by MDClone) of Clalit Health Services (CHS), Israel's largest healthcare organization. CHS insures nearly half the national population, with broad geographic coverage. Its electronic health records databases include longitudinal, de-identified information from multiple care sources. For the present study, dog bite cases were identified by ICD-9 diagnostic codes for dog bite. Case ascertainment was not restricted to emergency department encounters; dog bite diagnoses recorded in community-based settings, including primary care, urgent care, and outpatient clinic visits, were captured as well. All individuals of any age with a documented dog bite diagnosis during the study period were included. Given the use of anonymized, population-level administrative data, no exclusion criteria were applied. Data on civil defense siren activity were obtained from the Israel Home Front Command. Siren events were recorded by date and geographic region (North, Center, South) and aggregated on a monthly basis for each region. Siren activity was categorized into three predefined groups: months with no sirens, months with < 500 sirens (low exposure), and months with ≥ 500 sirens (high exposure). At the national level, the incidence of dog bite diagnoses was compared across these categories to assess whether months characterized by exposure to more civil defense sirens were associated with higher rates of dog bite injuries. Subsequently, the same analyses were stratified by geographic region (North, Center, South) to evaluate whether regional increases in exposure to civil defense sirens were associated with a higher regional dog bite incidence during the corresponding months. Injury severity was assessed using two clinically meaningful endpoints: hospital admission within 7 days of the index dog bite encounter and surgical intervention within 30 days. Relevant surgical interventions were defined as procedures requiring management in the operating room, including wound debridement, operative wound closure, skin grafting, and local, regional, or free-flap reconstruction. Surgical procedures performed within 30 days of the initial dog bite diagnosis were assumed to be related to the index injury. The need for operative intervention and/or hospital admission was used as a proxy for more severe injuries, reflecting greater tissue damage and clinical complexity. The primary outcome measure of the study was the monthly incidence of dog bite-related healthcare encounters, assessed at both the national and regional levels and evaluated in relation to monthly exposure to siren activity. The secondary outcome measure was injury severity in relation to level of siren exposure. Monthly counts of dog bite-related healthcare encounters were modeled using negative binomial regression to account for overdispersion in the count data (variance exceeding the mean), for which Poisson assumptions were not met. The dependent variable was the monthly number of dog bite incidents. The primary exposure was monthly siren activity, categorized a priori by level of exposure (0, < 500, or ≥ 500 sirens). Models included geographic region and were adjusted for seasonality and relevant demographic and socioeconomic covariates, including age group, sex, and socioeconomic status. Incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were reported. Statistical analyses were performed using R (version 4.3.2), and statistical significance was defined as a two-sided α level of 0.05. This study was based on the analysis of anonymized, retrospective administrative healthcare data and did not involve direct contact with human or animal subjects. The study was approved by the Institutional Review Board (Helsinki Committee) of Rabin Medical Center. Results A total of 63,285 dog bite-related healthcare encounters were identified during the study period, of which 36,661 occurred during months with no sirens, 18,971 during months with low siren exposure (< 500 sirens), and 7,653 during months with high siren exposure (≥ 500 sirens). The demographic, socioeconomic, geographic, seasonal, and clinical characteristics of the dog bite cases stratified by siren exposure status are summarized in Table 1 . Table 1 Patient, environmental, and dog-bite characteristics by level of siren exposure*. Variable Overall n = 63,285 No sirens n = 36,661 Low exposure n = 18,971 High exposure n = 7,653 Age group (years) 0–4 4,825 (7.6%) 2,667 (7.3%) 1,571 (8.3%) 587 (7.7%) 5–14 16,572 (26%) 9,523 (26%) 5,184 (27%) 1,865 (24%) 15–24 10,101 (16%) 5,919 (16%) 2,989 (16%) 1,193 (16%) 25–44 15,871 (25%) 9,290 (25%) 4,637 (24%) 1,944 (25%) 45–64 9,805 (15%) 5,716 (16%) 2,870 (15%) 1,219 (16%) >65 6,111 (9.7%) 3,546 (9.7%) 1,720 (9.1%) 845 (11%) Sex Female 25,164 (40%) 14,357 (39%) 7,573 (40%) 3,234 (42%) Male 38,121 (60%) 22,304 (61%) 11,398 (60%) 4,419 (58%) Socioeconomic status † Low 12,325 (19%) 7,236 (20%) 3,773 (20%) 1,316 (17%) Medium 34,131 (54%) 19,812 (54%) 10,082 (53%) 4,237 (55%) High 12,569 (20%) 7,510 (20%) 3,453 (18%) 1,606 (21%) No data 4,260 (6.7%) 2,103 (5.7%) 1,663 (8.8%) 494 (6.5%) Region South 9,141 (14%) 1,641 (4.5%) 6,623 (35%) 877 (11%) Center 33,150 (52%) 20,375 (56%) 8,124 (43%) 4,651 (61%) North 20,994 (33%) 14,645 (40%) 4,224 (22%) 2,125 (28%) Season of injury Spring 17,012 (27%) 9,625 (26%) 5,362 (28%) 2,025 (26%) Summer 17,048 (27%) 9,632 (26%) 5,241 (28%) 2,175 (28%) Autumn 15,633 (25%) 8,625 (24%) 4,245 (22%) 2,763 (36%) Winter 13,592 (21%) 8,779 (24%) 4,123 (22%) 690 (9.0%) Hospitalization within 7 days 452 (0.7%) 262 (0.7%) 131 (0.7%) 59 (0.8%) Surgical intervention within 30 days 11,389 (18%) 6,591 (18%) 3,382 (18%) 1,416 (19%) Notes: values are presented as n (%). * Siren exposure was defined by the number of monthly regional civil defense sirens: none (0), low (< 500), and high (≥ 500). † Socioeconomic status was classified according to the national socioeconomic index. Adjusted negative binomial regression models revealed an increase in dog bite incidence both in months with low siren exposure (IRR 1.15, 95% CI 1.13–1.18; P < 0.001) and in months with high siren exposure (IRR 1.33, 95% CI 1.28–1.37; P < 0.001) compared to months with no sirens (Table 2 ). The temporal patterns and exposure categorization are shown in Fig. 1 . The regional stratification by exposure category is presented in Fig. 2 . Table 2 Association between siren exposure level and monthly dog bite incidence Variable IRR CI 95% P -value Siren exposure category No siren Reference - - Low exposure (< 500 sirens) 1.15 1.13–1.18 < 0.001 High exposure ( ≥ 500 sirens) 1.33 1.28–1.37 < 0.001 Notes: IRRs estimated using negative binomial regression. Figure 1. Figure 2. Regarding secondary outcomes, 452 (0.7%) encounters were followed by hospitalization within 7 days and 11,389 (18.0%) by surgical intervention within 30 days (Table 1). In adjusted models, high siren exposure was associated with increased odds of surgical intervention within 30 days (OR 1.09, 95% CI 1.02-1.16; P =0.013). No statistically significant associations were observed for hospitalization within 7 days (Table 3). Table 3 Association between siren exposure level and injury severity among dog bite cases Outcome Siren exposure category Adjusted OR CI 95% P -value Surgical intervention within 30 days No siren Reference - - Low exposure (< 500 sirens) 1.04 0.99–1.10 0.11 High exposure ( ≥ 500 sirens) 1.09 1.02–1.16 0.013 Hospitalization within 7 days No siren Reference - - Low exposure (< 500 sirens) 1.06 0.85–1.33 0.60 High exposure ( ≥ 500 sirens) 1.09 0.81–1.44 0.60 Notes: Odds ratios estimated using multivariable logistic regression models. Abbreviations: OR, odds ratio; CI, confidence interval. Discussion In this nationwide retrospective study (2014-2025), we evaluated whether armed conflict-related environmental stressors, operationalized using civil defense siren activity, were associated with population-level variations in dog bite-related healthcare encounters. We identified a statistically significant graded association between the level of siren exposure and monthly dog bite incidence. In adjusted negative binomial models, compared to months with no sirens, months with low siren exposure (<500 sirens) were associated with a 15% increase in monthly dog bite incidence (IRR 1.15, 95% CI 1.13-1.18), and months with high exposure (≥500 sirens), with a 33% increase (IRR 1.33, 95% CI 1.28-1.37). Importantly, this study provides, to our knowledge, the first national-level evidence linking armed conflict-related environmental stressors to increased dog bite incidence. A key strength of this work is the use of siren alert data as a quantitative exposure measure. Civil defense sirens provide an objective, time-stamped, region-specific, and publicly documented indicator of environmental stress related to conflict escalation. Siren activity captures not only acute acoustic exposure but also broader contextual disruption during escalation periods, including shelter confinement, altered routines, and heightened mental strain, allowing for the assessment of population-level injury risk within a natural experiment framework. Notably, the graded siren exposure categorization offers a reproducible approach that extends beyond binary definitions of conflict versus non-conflict periods and enables evaluation of dose-response patterns at the population level. The observed association is biologically and behaviorally plausible [8-10]. High-intensity auditory stimuli have been associated with anxiety-related behavioral dysregulation in dogs, and companion animals are also known to be sensitive to changes in household stress and routine [5-7]. However, the present study was not designed to isolate a single mechanistic pathway. Rather, it adopts an ecological injury-risk perspective in which escalation-related stressors are expected to act simultaneously across multiple domains, including environmental context, human behavior and supervision patterns, and canine stress reactivity, resulting in a net population-level change in dog bite risk. Importantly, these pathways are not mutually exclusive and likely co-occur during periods of heightened threat exposure. Additionally, we assessed clinically meaningful severity endpoints reflecting healthcare utilization and system burden rather than behavior alone. Hospitalization within 7 days was uncommon and not significantly associated with siren exposure category. However, high-exposure months were associated with increased odds of surgical intervention within 30 days (OR 1.09, 95% CI 1.02-1.16). Although the effect size was small, it may be operationally relevant given the high baseline volume of dog bite encounters. Even modest increases in operative management may translate into a measurable surgical workload during periods when healthcare systems are simultaneously managing many escalation-related demands. Regional differences were observed in the adjusted models, with lower dog bite incidence in the North and South of the country compared with the Central region. The descriptive patterns shown in Figure 2 similarly indicate higher monthly counts of dog bite-related encounters in the Central region over the study period. However, the interpretation of geographic differences in dog bite incidence in Israel requires careful consideration of population distribution and displacement dynamics during escalation periods. The Central region includes a substantial proportion of the national population and has a higher population density, which may influence baseline exposure patterns and healthcare utilization. In addition, in Israel, escalation periods have historically involved a disproportionate siren burden in the South and, more recently, in the North. They may also involve substantial internal displacement and temporary relocation of residents from conflict-adjacent areas to central regions, altering both the geographic denominators at risk and the location of healthcare utilization. Thus, dog bite encounters may be redistributed toward the Central region irrespective of where exposure occurred. Consequently, region-level comparisons of dog bite incidence should be interpreted as reflecting both underlying demographic structure and time-varying population movement rather than stable geographic differences in risk. These findings have actionable public health and injury prevention implications. Preparedness during escalation periods, particularly in high-exposure areas, may benefit from incorporating dog bite injury mitigation into emergency department and surgical resource planning. Public guidance issued during siren events could include practical dog-handling recommendations, emphasizing child supervision, minimization of high-risk interactions in confined environments such as shelters, and use of restraints when feasible. Dog bite prevention may therefore represent a previously underrecognized component of civilian injury prevention during armed conflict. Several limitations merit consideration. This study relied on diagnostic coding and captured dog bite events resulting in healthcare utilization. Under-ascertainment of mild injuries is likely in routine periods and may be more pronounced during escalation periods when individuals may avoid seeking care for minor wounds. Such misclassification would be expected to be largely nondifferential and to bias effect estimates toward the null, suggesting that the observed associations may be conservative. In addition, data on dog breed, ownership status, household structure, and individual-level behavioral factors were unavailable, limiting mechanistic inference. Finally, the ecological design does not permit causal attribution at the individual level, and residual confounding may persist despite adjustment for demographics, seasonality, and region. In summary, using a nationwide dataset spanning more than a decade, we demonstrate a graded association between escalation-related environmental stress, quantified through civil defense siren burden, and population-level dog bite incidence. By leveraging a quantitative exposure measure rather than a binary conflict definition, this study strengthens evidence that armed conflict-related environmental stressors can modify civilian injury risk. These findings support integrating dog bite prevention and healthcare preparedness into civilian injury mitigation strategies during armed conflict. Abbreviations CHS Clalit Health Services Declarations Acknowledgements Not applicable. Author contributions S.S. conceived and designed the study, led data collection, performed the data analysis, interpreted the findings, and drafted the manuscript. L.S. contributed to data collection and data analysis. A.T. and S.F. provided statistical analysis and methodological support. D.A.-E. supervised the study, contributed to the interpretation of the results, and critically reviewed the manuscript for important intellectual content. A.O. supervised the study, contributed to the study design and interpretation of the results, and took a leading and full role in drafting and revising the manuscript. All authors reviewed and approved the final manuscript. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Data availability The datasets analyzed during the current study are based on anonymized administrative healthcare data and are subject to institutional data access regulations. Therefore, the data are not publicly available but may be accessed upon reasonable request and with appropriate institutional approvals. Ethics approval and consent to participate The study was conducted in adherence of the Declaration of Helsinki and approved by the Institutional Review Board of Rabin Medical Center (approval #RMC-0476-25) which waived the need for patient consent owing to the retrospective study design. Consent for publication Not applicable. Competing interests The authors declare no competing interests. References Tuckel PS, Milczarski W. The changing epidemiology of dog bite injuries in the United States, 2005-2018. Inj Epidemiol. 2020;7(1):57. doi: 10.1186/s40621-020-00281-y. Morgan M, Palmer J. Dog bites. BMJ. 2007;334(7590):413-7. doi: 10.1136/bmj.39105.659919.BE. Beerda B, Schilder MB, Van Hooff JA, De Vries HW. Manifestations of chronic and acute stress in dogs. Appl Anim Behav Sci 1997; 52:307-19. doi: 10.1016/S0168-1591(96)01131-8 Reisner IR, Shofer FS, Nance ML. Behavioral assessment of child-directed canine aggression. Inj Prev. 2007;13(5):348-51. doi: 10.1136/ip.2007.015396. Greff EK, Chou J, Parker E, Gatesy-Davis A, Clarkson ST, Hart LA. Stress-related behaviours in companion dogs exposed to common household noises, and owners' interpretation of their dogs' behavior. Front Vet Sci. 2021; 08. doi:org/10.3389/vets2021.760845 Blackwell EJ, Brandshaw JWS, Casey RA. Fear responses to noises in domestic dogs: prevalence, risk factors, and co-occurrence with other fear-related behaviour. Appl Anim Behav Sci 2013; 145:15-25. doi:10.1016/j.applanim.2012.12.004 Sherman BL, Mills DS. Canine anxieties and phobias: an update on separation anxiety and noise aversions. Vet Clin North Am Small Anim Pract. 2008;38(5):1081-106. doi: 10.1016/j.cvsm.2008.04.012. Levine ED, Ramos D, Mills DS. A prospective study of two self-help CD-based desensitization and counter-conditioning programmes with the use of Dog Appeasing Pheromone. Appl Anim Behav Sci. 2007;105(4):311-29. https://doi.org/10.1016/j.applanim.2006.11.006. Araujo JA, de Rivera C, Landsberg GM, Adams P, Milgram NM. Development and validation of a novel laboratory method of sound-induced fear and anxiety in beagle dogs. J Vet Behav 2013;8:204-12. doi: 10.1016/jveb.2012.10.008 Chmelfkova E, Bolechova P, Chaloupkova H, Svobodova I, Jovicc M, Sedmikova M. Salivary cortisol as a marker of acute stress in dogs: a review. Domest Anim Endocrinol 2020;72,106428. doi: 10.1016/j.domaniend.2019.106428 Yeng H-Y, Ogata N. The impact of COVID-19 pandemic on pet behavior and human-animal interaction. A longitudinal survey-based study in the United States. Front Vet Sci. 2023;10. doi: 10.3389/fvets.2023.1291703 Jezierski T, Camerlink I, chou J-Y, Pedon R. Changes in the health and behavior of ped dogs during the COVID-19 pandemic as reported by the owners. Appl Anim Behav Sci 2021;241. doi: 10.1016/japplanim.2021.105395 Hunt MG, Bogue K, Rohrbaugh N. Pet Ownership and evacuation prior to hurricane Irene. Animals (Basel). 2012;2(4):529-39. doi: 10.3390/ani2040529. Day AM. Companion animals and natural disasters. A systematic review of the literature. Int J Disaster Risk Reduction. 2017;24:81-90. doi: 10.1016/j.ijdrr.2017.05.015 Warner GS. Increased incidence of domestic animal bites following a disaster due to natural hazards. Prehosp Disaster Med. 2010;25(2):188-190. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Apr, 2026 Read the published version in Injury Epidemiology → Version 1 posted Editorial decision: Revision requested 27 Mar, 2026 Reviews received at journal 26 Mar, 2026 Reviews received at journal 25 Mar, 2026 Reviews received at journal 21 Mar, 2026 Reviewers agreed at journal 06 Mar, 2026 Reviewers agreed at journal 02 Mar, 2026 Reviewers agreed at journal 02 Mar, 2026 Reviewers invited by journal 02 Mar, 2026 Editor assigned by journal 01 Mar, 2026 Submission checks completed at journal 01 Mar, 2026 First submitted to journal 23 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8950975","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":600760930,"identity":"20c205d9-939b-4a5c-be63-9f4b9be77ea6","order_by":0,"name":"Shon Shabat","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYHACNhCRwMDewHiAoUACKmhgQYQWngMMBxgMJKB6DCSI0CKRANLCAFOKW4tue/uzBx931OXxz3z84MAPA4s6Bvbexy8QLsQEZmfOmBvOPHO4WOJ2msHBHpDDeI6bWeBzmNmNHDZp3rYDiQ23cxgO8IC0SKSxGeDVcv/5M6CWusT5N88wHPxDlJYbDGZALcyJG27wMByG2sL8AK+WMzlmkjPbDiduPJNmcFjGQEKyjecYG0MCPi3Hjz+T+Ah02Lzjhx8+fFNRx8/P3sb84cMfG5xaMAEwmtiAcUQiYP5Aqo5RMApGwSgY1gAA9FFPk/rjYrYAAAAASUVORK5CYII=","orcid":"","institution":"Rabin Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Shon","middleName":"","lastName":"Shabat","suffix":""},{"id":600760931,"identity":"dbafbd9f-d9f1-4139-b34b-5c8a86cdb44e","order_by":1,"name":"Lia Schoenfeld","email":"","orcid":"","institution":"Rabin Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Lia","middleName":"","lastName":"Schoenfeld","suffix":""},{"id":600760932,"identity":"38b5b164-cdb7-4236-b40d-11f8ff92d010","order_by":2,"name":"Adi Turjeman","email":"","orcid":"","institution":"Rabin Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Adi","middleName":"","lastName":"Turjeman","suffix":""},{"id":600760933,"identity":"9f845253-4a73-4b68-b1f6-a5bf86486e8a","order_by":3,"name":"Sigal Fleishman","email":"","orcid":"","institution":"Rabin Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Sigal","middleName":"","lastName":"Fleishman","suffix":""},{"id":600760934,"identity":"37acfd37-5e05-44d1-9863-bfde803fb1cb","order_by":4,"name":"Dean Ad-El","email":"","orcid":"","institution":"Rabin Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Dean","middleName":"","lastName":"Ad-El","suffix":""},{"id":600760935,"identity":"d779cb78-576e-4ea0-a064-a49c26d64e63","order_by":5,"name":"Asaf Olshinka","email":"","orcid":"","institution":"Rabin Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Asaf","middleName":"","lastName":"Olshinka","suffix":""}],"badges":[],"createdAt":"2026-02-23 22:23:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8950975/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8950975/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40621-026-00681-6","type":"published","date":"2026-04-24T15:58:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":104403817,"identity":"0adc0d7c-12f3-4a47-9573-b4dfcb6ef0b7","added_by":"auto","created_at":"2026-03-11 12:19:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":100210,"visible":true,"origin":"","legend":"\u003cp\u003eDog bite-related healthcare encounters by siren exposure category in Israel (2014-2025). (A) Total number of dog bite-related healthcare encounters aggregated across the study period, stratified by monthly civil defense siren exposure: no sirens, low exposure (\u0026lt;500 sirens per month), and high exposure (≥500 sirens per month). (B) Adjusted incidence rate ratios (IRRs) with 95% confidence intervals (CIs) for dog bite incidence by siren exposure category, estimated using multivariable negative binomial regression models. Months with no sirens served as the reference category (IRR = 1). Models were adjusted for geographic region, seasonality, age group, sex, and socioeconomic status.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8950975/v1/f0dc2c5393eca8612800ae3e.png"},{"id":104178814,"identity":"3b6e05ff-2952-4343-a2c5-a85126bd6666","added_by":"auto","created_at":"2026-03-08 16:59:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":43442,"visible":true,"origin":"","legend":"\u003cp\u003eMonthly dog bite-related healthcare encounters by geographic region and siren exposure category in Israel (2014-2025).\u003cbr\u003e\nBars represent monthly counts of dog bite-related healthcare encounters stratified by geographic region (Center, North, South) and level of civil defense siren exposure: no sirens, low exposure (\u0026lt;500 sirens per month), and high exposure (≥500 sirens per month). This figure illustrates temporal and regional variation in dog bite incidence in relation to escalation-related environmental stress.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8950975/v1/3ebf68c3c02a32b5b5c2435d.png"},{"id":107927874,"identity":"98df8389-3489-495f-b9c9-83e7375fa87e","added_by":"auto","created_at":"2026-04-27 16:05:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":422942,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8950975/v1/4afa7c49-8133-461b-bdb9-5ada0df244e2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eDog bite injuries and armed conflict-related environmental stressors: a nationwide population-based time-series study\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eDog bites are a significant and growing public health concern worldwide, with millions of cases reported annually. In the United States, dog bites rank among the leading causes of nonfatal emergency department visits, with approximately 344,000 encounters per year and an incidence of up to 225 per 100,000 population [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Dog bite injuries pose a substantial physical, psychological, and economic burden, particularly among pediatric populations [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The etiology is multifactorial, involving dog-specific characteristics such as breed, sex, training, and behavioral traits, in addition to human behavior and environmental stressors that may alter canine responses. The stress exposure may be either acute or chronic [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong the potential environmental stressors, several studies have identified loud noises as major contributing factors to anxiety-related and behavior dysregulation and aggression in dogs [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The most common noises that elicit fear responses are high-decibel fireworks, thunderstorms, sirens, and explosions [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Experimental studies examining controlled acoustic environments reported physiological stress responses in dogs, including elevated cortisol levels and increased heart rate, supporting the biological plausibility of noise-induced behavioral changes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBesides such external stimuli, dogs are sensitive to their living conditions and the emotional states and behavioral patterns of their owners. Heightened stress, fear, and anxiety among caregivers may contribute to altered animal handling, reduced tolerance, and more unpredictable interactions, potentially lowering the threshold for aggressive canine responses. During the COVID-19 pandemic, multiple studies reported an increase in dog bite injuries, particularly among children, which were attributed to disrupted routines, increased household stress, reduced supervision, and prolonged close contact between people and pets [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. These observations underscore how sustained environmental and psychosocial stressors can influence human-animal interactions and increase the risk of dog bite injuries.\u003c/p\u003e \u003cp\u003eBeyond identifying individual-level determinants, dog-bite injuries can be studied using an ecological injury-risk model, examining changes in exposure patterns and susceptibility as a function of multiple, interacting factors across different levels of organization within whole environmental systems. In this context, armed conflict represents a unique population-level stressor capable of modifying the risk of dog bite injury through different, concurrent, pathways. It may simultaneously alter physical environmental conditions (e.g., high-intensity auditory stimuli including civil defense sirens, explosions, gunfire, and noise generated by aircraft, drones, and incoming or outgoing projectiles), human behavior and routines (e.g., time spent at home and supervision patterns), and psychosocial vulnerability (e.g., heightened anxiety and emotional tension). The stressors may occur as discrete acute events or as repeated and prolonged episodes over weeks or months. Accordingly, research conducted in disaster areas revealed significant behavioral changes in companion animals including increased anxiety, heightened reactivity, and unpredictable conduct [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTaken together, these findings suggest that armed conflict-related environmental stressors may increase both human and canine stress, thereby modifying human-animal interaction dynamics and increasing the likelihood of bite events, potentially with greater injury severity.\u003c/p\u003e \u003cp\u003eDespite the growing recognition of the behavioral effects of environmental stressors on companion animals, empirical data on the relationship between armed conflict-related environmental stress and dog bite incidence remain limited. To our knowledge, there are no published systematic, population-level studies of armed conflict stressors as modifiers of injury risk. Israel's recurrent exposure to fluctuating intensities of armed conflict over the past decade, characterized by intermittent periods of escalation interspersed with intervals of relative calm, provides a unique natural experiment to examine this issue. Moreover, the nationwide availability of civil defense siren records makes it possible to use air raid alerts as a precise, objective proxy to quantify acute and cumulative environmental stress exposure, overall and across time and geography.\u003c/p\u003e \u003cp\u003eThe primary aim of the present study was to evaluate the association between armed conflict-related environmental stress and the incidence of dog bite injuries requiring medical evaluation using civil defense siren activity as an objective proxy for periods of escalation. The secondary aim were to determine whether the level of stressor is related to the severity of injury, as reflected by the need for hospital admission or operative management.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA retrospective, nationwide, observational study was conducted, spanning the decade from 2014 to 2025, during which the Israeli population was exposed to a cycle of high-intensity military conflicts and heightened civil defense siren activity (escalation) interspersed with intervals of calm (de-escalation). Healthcare encounter data were extracted at the end of the study from the research data-sharing platform (powered by MDClone) of Clalit Health Services (CHS), Israel's largest healthcare organization. CHS insures nearly half the national population, with broad geographic coverage. Its electronic health records databases include longitudinal, de-identified information from multiple care sources. For the present study, dog bite cases were identified by ICD-9 diagnostic codes for dog bite. Case ascertainment was not restricted to emergency department encounters; dog bite diagnoses recorded in community-based settings, including primary care, urgent care, and outpatient clinic visits, were captured as well. All individuals of any age with a documented dog bite diagnosis during the study period were included. Given the use of anonymized, population-level administrative data, no exclusion criteria were applied.\u003c/p\u003e \u003cp\u003eData on civil defense siren activity were obtained from the Israel Home Front Command. Siren events were recorded by date and geographic region (North, Center, South) and aggregated on a monthly basis for each region. Siren activity was categorized into three predefined groups: months with no sirens, months with \u0026lt;\u0026thinsp;500 sirens (low exposure), and months with \u0026ge;\u0026thinsp;500 sirens (high exposure). At the national level, the incidence of dog bite diagnoses was compared across these categories to assess whether months characterized by exposure to more civil defense sirens were associated with higher rates of dog bite injuries. Subsequently, the same analyses were stratified by geographic region (North, Center, South) to evaluate whether regional increases in exposure to civil defense sirens were associated with a higher regional dog bite incidence during the corresponding months.\u003c/p\u003e \u003cp\u003eInjury severity was assessed using two clinically meaningful endpoints: hospital admission within 7 days of the index dog bite encounter and surgical intervention within 30 days. Relevant surgical interventions were defined as procedures requiring management in the operating room, including wound debridement, operative wound closure, skin grafting, and local, regional, or free-flap reconstruction. Surgical procedures performed within 30 days of the initial dog bite diagnosis were assumed to be related to the index injury. The need for operative intervention and/or hospital admission was used as a proxy for more severe injuries, reflecting greater tissue damage and clinical complexity.\u003c/p\u003e \u003cp\u003eThe primary outcome measure of the study was the monthly incidence of dog bite-related healthcare encounters, assessed at both the national and regional levels and evaluated in relation to monthly exposure to siren activity. The secondary outcome measure was injury severity in relation to level of siren exposure.\u003c/p\u003e \u003cp\u003eMonthly counts of dog bite-related healthcare encounters were modeled using negative binomial regression to account for overdispersion in the count data (variance exceeding the mean), for which Poisson assumptions were not met. The dependent variable was the monthly number of dog bite incidents. The primary exposure was monthly siren activity, categorized a priori by level of exposure (0, \u0026lt;\u0026thinsp;500, or \u0026ge;\u0026thinsp;500 sirens). Models included geographic region and were adjusted for seasonality and relevant demographic and socioeconomic covariates, including age group, sex, and socioeconomic status. Incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were reported. Statistical analyses were performed using R (version 4.3.2), and statistical significance was defined as a two-sided α level of 0.05.\u003c/p\u003e \u003cp\u003eThis study was based on the analysis of anonymized, retrospective administrative healthcare data and did not involve direct contact with human or animal subjects. The study was approved by the Institutional Review Board (Helsinki Committee) of Rabin Medical Center.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 63,285 dog bite-related healthcare encounters were identified during the study period, of which 36,661 occurred during months with no sirens, 18,971 during months with low siren exposure (\u0026lt;\u0026thinsp;500 sirens), and 7,653 during months with high siren exposure (\u0026ge;\u0026thinsp;500 sirens). The demographic, socioeconomic, geographic, seasonal, and clinical characteristics of the dog bite cases stratified by siren exposure status are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient, environmental, and dog-bite characteristics by level of siren exposure*.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;63,285\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo sirens\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;36,661\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow exposure\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;18,971\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh exposure\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;7,653\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,825 (7.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,667 (7.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,571 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e587 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16,572 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9,523 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5,184 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,865 (24%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10,101 (16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5,919 (16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2,989 (16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,193 (16%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15,871 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9,290 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4,637 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,944 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e45\u0026ndash;64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9,805 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5,716 (16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2,870 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,219 (16%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6,111 (9.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3,546 (9.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,720 (9.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e845 (11%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25,164 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14,357 (39%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7,573 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3,234 (42%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38,121 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22,304 (61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11,398 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4,419 (58%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocioeconomic status\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12,325 (19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7,236 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3,773 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,316 (17%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34,131 (54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19,812 (54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10,082 (53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4,237 (55%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12,569 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7,510 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3,453 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,606 (21%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,260 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,103 (5.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,663 (8.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e494 (6.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9,141 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,641 (4.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6,623 (35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e877 (11%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCenter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33,150 (52%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20,375 (56%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8,124 (43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4,651 (61%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20,994 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14,645 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4,224 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2,125 (28%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeason of injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17,012 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9,625 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5,362 (28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2,025 (26%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSummer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17,048 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9,632 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5,241 (28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2,175 (28%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAutumn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15,633 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8,625 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4,245 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2,763 (36%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWinter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13,592 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8,779 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4,123 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e690 (9.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospitalization within 7 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e452 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e262 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e131 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical intervention within 30 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11,389 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6,591 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3,382 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,416 (19%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNotes: values are presented as n (%).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e* Siren exposure was defined by the number of monthly regional civil defense sirens: none (0), low (\u0026lt;\u0026thinsp;500), and high (\u0026ge;\u0026thinsp;500).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003eSocioeconomic status was classified according to the national socioeconomic index.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAdjusted negative binomial regression models revealed an increase in dog bite incidence both in months with low siren exposure (IRR 1.15, 95% CI 1.13\u0026ndash;1.18; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and in months with high siren exposure (IRR 1.33, 95% CI 1.28\u0026ndash;1.37; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to months with no sirens (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The temporal patterns and exposure categorization are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The regional stratification by exposure category is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between siren exposure level and monthly dog bite incidence\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIRR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCI 95%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSiren exposure category\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo siren\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow exposure (\u0026lt;\u0026thinsp;500 sirens)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.13\u0026ndash;1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh exposure (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;500 sirens)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.28\u0026ndash;1.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNotes: IRRs estimated using negative binomial regression.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003cstrong\u003eFigure 1.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 2.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegarding secondary outcomes, 452 (0.7%) encounters were followed by hospitalization within 7 days and 11,389 (18.0%) by surgical intervention within 30 days (Table 1). In adjusted models, high siren exposure was associated with increased odds of surgical intervention within 30 days (OR 1.09, 95% CI 1.02-1.16;\u0026nbsp;\u003cem\u003eP\u003c/em\u003e=0.013). No statistically significant associations were observed for hospitalization within 7 days (Table 3).\u0026nbsp;\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between siren exposure level and injury severity among dog bite cases\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSiren exposure category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdjusted OR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCI 95%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical intervention within 30 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo siren\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow exposure (\u0026lt;\u0026thinsp;500 sirens)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.99\u0026ndash;1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh exposure (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;500 sirens)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.02\u0026ndash;1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospitalization within 7 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo siren\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow exposure (\u0026lt;\u0026thinsp;500 sirens)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.85\u0026ndash;1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh exposure (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;500 sirens)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.81\u0026ndash;1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNotes: Odds ratios estimated using multivariable logistic regression models.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAbbreviations: OR, odds ratio; CI, confidence interval.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this nationwide retrospective study (2014-2025), we evaluated whether armed conflict-related environmental stressors, operationalized using civil defense siren activity, were associated with population-level variations in dog bite-related healthcare encounters. We identified a statistically significant graded association between the level of siren exposure and monthly dog bite incidence. In adjusted negative binomial models, compared to months with no sirens, months with low siren exposure (\u0026lt;500 sirens) were associated with a 15% increase in monthly dog bite incidence (IRR 1.15, 95% CI 1.13-1.18), and months with high exposure (\u0026ge;500 sirens), with a 33% increase (IRR 1.33, 95% CI 1.28-1.37). Importantly, this study provides, to our knowledge, the first national-level evidence linking armed conflict-related environmental stressors to increased dog bite incidence.\u003c/p\u003e\n\u003cp\u003eA key strength of this work is the use of siren alert data as a quantitative exposure measure. Civil defense sirens provide an objective, time-stamped, region-specific, and publicly documented indicator of environmental stress related to conflict escalation. Siren activity captures not only acute acoustic exposure but also broader contextual disruption during escalation periods, including shelter confinement, altered routines, and heightened mental strain, allowing for the assessment of population-level injury risk within a natural experiment framework. Notably, the graded siren exposure categorization offers a reproducible approach that extends beyond binary definitions of conflict versus non-conflict periods and enables evaluation of dose-response patterns at the population level.\u003c/p\u003e\n\u003cp\u003eThe observed association is biologically and behaviorally plausible [8-10]. High-intensity auditory stimuli have been associated with anxiety-related behavioral dysregulation in dogs, and companion animals are also known to be sensitive to changes in household stress and routine [5-7]. However, the present study was not designed to isolate a single mechanistic pathway. Rather, it adopts an ecological injury-risk perspective in which escalation-related stressors are expected to act simultaneously across multiple domains, including environmental context, human behavior and supervision patterns, and canine stress reactivity, resulting in a net population-level change in dog bite risk. Importantly, these pathways are not mutually exclusive and likely co-occur during periods of heightened threat exposure.\u003c/p\u003e\n\u003cp\u003eAdditionally, we assessed clinically meaningful severity endpoints reflecting healthcare utilization and system burden rather than behavior alone. Hospitalization within 7 days was uncommon and not significantly associated with siren exposure category. However, high-exposure months were associated with increased odds of surgical intervention within 30 days (OR 1.09, 95% CI 1.02-1.16). Although the effect size was small, it may be operationally relevant given the high baseline volume of dog bite encounters. Even modest increases in operative management may translate into a measurable surgical workload during periods when healthcare systems are simultaneously managing many escalation-related demands.\u003c/p\u003e\n\u003cp\u003eRegional differences were observed in the adjusted models, with lower dog bite incidence in the North and South of the country compared with the Central region. The descriptive patterns shown in Figure 2 similarly indicate higher monthly counts of dog bite-related encounters in the Central region over the study period. However, the interpretation of geographic differences in dog bite incidence in Israel requires careful consideration of population distribution and displacement dynamics during escalation periods. The Central region includes a substantial proportion of the national population and has a higher population density, which may influence baseline exposure patterns and healthcare utilization. In addition, in Israel, escalation periods have historically involved a disproportionate siren burden in the South and, more recently, in the North. They may also involve substantial internal displacement and temporary relocation of residents from conflict-adjacent areas to central regions, altering both the geographic denominators at risk and the location of healthcare utilization. Thus, dog bite encounters may be redistributed toward the Central region irrespective of where exposure occurred. Consequently, region-level comparisons of dog bite incidence should be interpreted as reflecting both underlying demographic structure and time-varying population movement rather than stable geographic differences in risk.\u003c/p\u003e\n\u003cp\u003eThese findings have actionable public health and injury prevention implications. Preparedness during escalation periods, particularly in high-exposure areas, may benefit from incorporating dog bite injury mitigation into emergency department and surgical resource planning. Public guidance issued during siren events could include practical dog-handling recommendations, emphasizing child supervision, minimization of high-risk interactions in confined environments such as shelters, and use of restraints when feasible. Dog bite prevention may therefore represent a previously underrecognized component of civilian injury prevention during armed conflict.\u003c/p\u003e\n\u003cp\u003eSeveral limitations merit consideration. This study relied on diagnostic coding and captured dog bite events resulting in healthcare utilization. Under-ascertainment of mild injuries is likely in routine periods and may be more pronounced during escalation periods when individuals may avoid seeking care for minor wounds. Such misclassification would be expected to be largely nondifferential and to bias effect estimates toward the null, suggesting that the observed associations may be conservative. In addition, data on dog breed, ownership status, household structure, and individual-level behavioral factors were unavailable, limiting mechanistic inference. Finally, the ecological design does not permit causal attribution at the individual level, and residual confounding may persist despite adjustment for demographics, seasonality, and region.\u003c/p\u003e\n\u003cp\u003eIn summary, using a nationwide dataset spanning more than a decade, we demonstrate a graded association between escalation-related environmental stress, quantified through civil defense siren burden, and population-level dog bite incidence. By leveraging a quantitative exposure measure rather than a binary conflict definition, this study strengthens evidence that armed conflict-related environmental stressors can modify civilian injury risk. These findings support integrating dog bite prevention and healthcare preparedness into civilian injury mitigation strategies during armed conflict.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eCHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003eClalit Health Services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS.S. conceived and designed the study, led data collection, performed the data analysis, interpreted the findings, and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eL.S. contributed to data collection and data analysis.\u003c/p\u003e\n\u003cp\u003eA.T. and S.F. provided statistical analysis and methodological support.\u003c/p\u003e\n\u003cp\u003eD.A.-E. supervised the study, contributed to the interpretation of the results, and critically reviewed the manuscript for important intellectual content.\u003c/p\u003e\n\u003cp\u003eA.O. supervised the study, contributed to the study design and interpretation of the results, and took a leading and full role in drafting and revising the manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analyzed during the current study are based on anonymized administrative healthcare data and are subject to institutional data access regulations. Therefore, the data are not publicly available but may be accessed upon reasonable request and with appropriate institutional approvals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in adherence of the Declaration of Helsinki and approved by the Institutional Review Board of Rabin Medical Center (approval #RMC-0476-25) which waived the need for patient consent owing to the retrospective study design.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTuckel PS, Milczarski W. The changing epidemiology of dog bite injuries in the United States, 2005-2018. Inj Epidemiol. 2020;7(1):57. doi: 10.1186/s40621-020-00281-y. \u003c/li\u003e\n\u003cli\u003eMorgan M, Palmer J. Dog bites. BMJ. 2007;334(7590):413-7. doi: 10.1136/bmj.39105.659919.BE.\u003c/li\u003e\n\u003cli\u003eBeerda B, Schilder MB, Van Hooff JA, De Vries HW. Manifestations of chronic and acute stress in dogs. Appl Anim Behav Sci 1997; 52:307-19. doi: 10.1016/S0168-1591(96)01131-8\u003c/li\u003e\n\u003cli\u003eReisner IR, Shofer FS, Nance ML. Behavioral assessment of child-directed canine aggression. Inj Prev. 2007;13(5):348-51. doi: 10.1136/ip.2007.015396.\u003c/li\u003e\n\u003cli\u003eGreff EK, Chou J, Parker E, Gatesy-Davis A, Clarkson ST, Hart LA. Stress-related behaviours in companion dogs exposed to common household noises, and owners\u0026apos; interpretation of their dogs\u0026apos; behavior. Front Vet Sci. 2021; 08. doi:org/10.3389/vets2021.760845\u003c/li\u003e\n\u003cli\u003eBlackwell EJ, Brandshaw JWS, Casey RA. Fear responses to noises in domestic dogs: prevalence, risk factors, and co-occurrence with other fear-related behaviour. Appl Anim Behav Sci 2013; 145:15-25. doi:10.1016/j.applanim.2012.12.004\u003c/li\u003e\n\u003cli\u003eSherman BL, Mills DS. Canine anxieties and phobias: an update on separation anxiety and noise aversions. Vet Clin North Am Small Anim Pract. 2008;38(5):1081-106. doi: 10.1016/j.cvsm.2008.04.012. \u003c/li\u003e\n\u003cli\u003eLevine ED, Ramos D, Mills DS. A prospective study of two self-help CD-based desensitization and counter-conditioning programmes with the use of Dog Appeasing Pheromone. Appl Anim Behav Sci. 2007;105(4):311-29. https://doi.org/10.1016/j.applanim.2006.11.006.\u003c/li\u003e\n\u003cli\u003eAraujo JA, de Rivera C, Landsberg GM, Adams P, Milgram NM. Development and validation of a novel laboratory method of sound-induced fear and anxiety in beagle dogs. J Vet Behav 2013;8:204-12. doi: 10.1016/jveb.2012.10.008\u003c/li\u003e\n\u003cli\u003eChmelfkova E, Bolechova P, Chaloupkova H, Svobodova I, Jovicc M, Sedmikova M. Salivary cortisol as a marker of acute stress in dogs: a review. Domest Anim Endocrinol 2020;72,106428. doi: 10.1016/j.domaniend.2019.106428\u003c/li\u003e\n\u003cli\u003eYeng H-Y, Ogata N. The impact of COVID-19 pandemic on pet behavior and human-animal interaction. A longitudinal survey-based study in the United States. Front Vet Sci. 2023;10. doi: 10.3389/fvets.2023.1291703\u003c/li\u003e\n\u003cli\u003eJezierski T, Camerlink I, chou J-Y, Pedon R. Changes in the health and behavior of ped dogs during the COVID-19 pandemic as reported by the owners. Appl Anim Behav Sci 2021;241. doi: 10.1016/japplanim.2021.105395 \u003c/li\u003e\n\u003cli\u003eHunt MG, Bogue K, Rohrbaugh N. Pet Ownership and evacuation prior to hurricane Irene. Animals (Basel). 2012;2(4):529-39. doi: 10.3390/ani2040529.\u003c/li\u003e\n\u003cli\u003eDay AM. Companion animals and natural disasters. A systematic review of the literature. Int J Disaster Risk Reduction. 2017;24:81-90. doi: 10.1016/j.ijdrr.2017.05.015\u003c/li\u003e\n\u003cli\u003eWarner GS. Increased incidence of domestic animal bites following a disaster due to natural hazards. Prehosp Disaster Med. 2010;25(2):188-190. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"injury-epidemiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"inep","sideBox":"Learn more about [Injury Epidemiology](https://injepijournal.biomedcentral.com)","snPcode":"40621","submissionUrl":"https://submission.nature.com/new-submission/40621/3","title":"Injury Epidemiology","twitterHandle":"@InjuryEpi","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Dog bite, Armed conflict, Environmental stressors, Injury prevention, Population-based study","lastPublishedDoi":"10.21203/rs.3.rs-8950975/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8950975/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Dog bite injuries pose a substantial public health burden worldwide. Environmental and acoustic stressors may contribute to canine behavioral dysregulation. However, there are as yet no population-level studies evaluating whether the incidence of dog bites increases during periods of armed conflict. The present study was conducted in Israel where the population is routinely exposed to an episodic pattern of high-intensity conflicts (escalation) alternating with periods of calm (de-escalation), providing a unique natural experiment to examine the effect of environmental stressors on population-level modifiers of injury risk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This nationwide retrospective observational study covered the decade from 2014 to 2025. Healthcare-encounter data were used to capture dog bite-related diagnoses in both hospital and community settings. Exposure to armed conflict-related environmental stress was operationalized using the number of civil defense sirens per month, categorized as none (0), low (\u0026lt;500), or high (≥500) and aggregated by geographic region (North, Center, South). Monthly dog bite counts were modeled using negative binomial regression adjusted for region, seasonality, age group, sex, and socioeconomic status. Secondary outcomes were hospitalization within 7 days and surgical intervention within 30 days, reflecting injury severity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: A total of 63,285 dog bite-related encounters were identified. Compared to months with no sirens, adjusted dog bite incidence increased by 15% during low-exposure months (IRR 1.15, 95% CI 1.13-1.18) and by 33% during high-exposure months (IRR 1.33, 95% CI 1.28-1.37), demonstrating a graded exposure-response association.\u003c/p\u003e\n\u003cp\u003eHigh exposure was associated with increased odds of surgical intervention within 30 days (OR 1.09, 95% CI 1.02-1.16; \u003cem\u003eP\u003c/em\u003e=0.013).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: This study provides the first population-level evidence linking armed conflict-related environmental stressors to increased dog bite incidence, using a quantitative graded exposure measure rather than a binary conflict-period definition. Dog bite prevention and healthcare preparedness should be taken into consideration in civilian injury mitigation strategies during armed conflict.\u003c/p\u003e","manuscriptTitle":"Dog bite injuries and armed conflict-related environmental stressors: a nationwide population-based time-series study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-08 16:59:28","doi":"10.21203/rs.3.rs-8950975/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-27T17:13:44+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-27T02:12:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-25T13:59:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-21T21:16:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"67223096003131363853371545408170504503","date":"2026-03-06T19:34:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"322040503379643835265030390653951766559","date":"2026-03-02T16:11:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"324932516502069089534640845986551195857","date":"2026-03-02T15:56:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-02T15:41:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-02T04:21:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-02T04:21:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"Injury Epidemiology","date":"2026-02-23T22:14:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"injury-epidemiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"inep","sideBox":"Learn more about [Injury Epidemiology](https://injepijournal.biomedcentral.com)","snPcode":"40621","submissionUrl":"https://submission.nature.com/new-submission/40621/3","title":"Injury Epidemiology","twitterHandle":"@InjuryEpi","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eb96366a-03e1-4561-a515-df12a4f9a5e6","owner":[],"postedDate":"March 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T16:03:24+00:00","versionOfRecord":{"articleIdentity":"rs-8950975","link":"https://doi.org/10.1186/s40621-026-00681-6","journal":{"identity":"injury-epidemiology","isVorOnly":false,"title":"Injury Epidemiology"},"publishedOn":"2026-04-24 15:58:52","publishedOnDateReadable":"April 24th, 2026"},"versionCreatedAt":"2026-03-08 16:59:28","video":"","vorDoi":"10.1186/s40621-026-00681-6","vorDoiUrl":"https://doi.org/10.1186/s40621-026-00681-6","workflowStages":[]},"version":"v1","identity":"rs-8950975","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8950975","identity":"rs-8950975","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}